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uw <br /> SAN JOAQUIN LOCAL HEALTH DIS7'?lt.T <br /> FOH OFFICE USE: f.' 1601 E. Hazelton Ave. , Stockton, Calif, <br /> s <br /> Telephone: (209) 466-6781 n �� -c�, � <br /> APPLICATION FOR WELL CONSTRUCTION OR PUP1P PERMIT '. yl it No. �5 � <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued - 10-7 <br /> (Complete In Triplicate) <br /> kpplication is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> 560 ( w �E(.T -E4 �J. <br /> / / ft Fol)OB ADDRESS/LOCATION s- CENSUS TRACT 01( - <br /> -'Amer's <br /> Name ' 3 �.�('��y_ C Phone <br /> Address 1� C.l 5 ,�1 City <br /> — n <br /> )ontractor's Name r' / //� ,, / (� f_ i/ ; t' ('•: License # tel_; Phone " = c <br /> 'YPE OF WORK (Check) : NEW WELL / DEEPEN /� RECONDITION /� DESTRUCTION /7 Q <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT /-T IS <br /> Other <br /> T: <br /> )ISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> PROPERTY LINE - PRIVATE DOMESTIC WELL — PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (� <br /> Industrial Cable Tool Dia, of Well Excavation <br /> Domestic/private Drilled Dia. of Well Casing / (- <br /> �— <br /> Domestic/public Driven Gauge of CasingFv 7 <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> Cathodic Protection Rotary Type of Grout <br /> Disposal Other Other Information <br /> Geophysical Surface Seal Installed BY: ,� p <br /> -PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: / / State Work Done \ <br /> 'UMP :REPAIR: /-7 State Work Done <br /> - ES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> 1 hereby Agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> Lad the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting thewell in use. The above <br /> .nformatipn is true to the best of my knowledge and belief. I WILL CALL FOR A GROUT INSPECTION <br /> RIOR TO GROUTING D A FINAL INSPECTION. <br /> SIGNED <br /> �g ' � TITLE <br /> (DRAW PLOT PLAN ON REVERSE SIDE) <br /> ARTMEN USE ONLY <br /> PHASE I ' �p <br /> -APPLICATION ACCEPT L (7LS DATE 20- <br /> DDITIONAL COMMENTS: <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSPECTION BY / ,..4r DATE r <br /> E H 1426 Rev. 1-74 �.P <br />